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The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor the client.
- D. Recheck the respiratory rate in 30 minutes.
Correct Answer: B
Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld
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The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?
- A. allowing clients in a substance abuse facility to be interviewed by the media
- B. violating the HIPAA need to know rule
- C. releasing information about a minor without parental consent
- D. There is no violation.
Correct Answer: B
Rationale: The nurse violated HIPAA by allowing the filming of other clients without their consent, as this discloses protected health information (PHI) without authorization.
The doctor has prescribed Claratin (loratidine) for a client with seasonal allergies. The feature that separates Claratin from other antihistamines such as diphenhydramine is that the medication:
- A. Is nonsedating
- B. Stimulates appetite
- C. Is used for motion sickness
- D. Is less expensive
Correct Answer: A
Rationale: Loratadine (Claritin) is a second-generation antihistamine that is nonsedating, unlike first-generation antihistamines like diphenhydramine.
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
- A. Anesthetize the cornea
- B. Dilate the pupils
- C. Constrict the pupils
- D. Paralyze the muscles of accommodation
Correct Answer: C
Rationale: Miotics constrict the pupils, increasing aqueous humor outflow to reduce intraocular pressure in glaucoma.
Vitamin K is administered to the newborn shortly after birth for which of the following reasons?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Vitamin K is given to newborns to facilitate clotting, preventing hemorrhagic disease due to low vitamin K levels.
The nurse is working with a client who experiences orthostatic hypotension. Which suggestion would benefit the client?
- A. Sleep completely flat and do not use any pillows to prop your head.'
- B. Wear your support stockings when you sleep.'
- C. Take your blood pressure medicine immediately before trying to stand up.'
- D. Do not drink any liquids after 8 p.m.'
- E. None
- F. all the above
Correct Answer: E
Rationale: None of the options directly address orthostatic hypotension effectively. Support stockings during the day (not sleep), slow position changes, and adequate hydration are better strategies.